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  • 1. Bengtsson, A
    et al.
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare. [external].
    Karlsson, T
    Hjalmarson, Å
    The epidemiology of a coronary waiting list. A description of all patients1994In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, ISSN 0954-6820, Vol. 235, no 3, p. 263-269Article in journal (Refereed)
    Abstract [en]

    Keywords: cardiac symptoms; chest pain; coronary revascularization; delay; ischaemic heart disease; nervous reactions; waiting list Abstract. Objectives. To describe the characteristics and the severity of symptoms amongst patients on the waiting list for possible coronary revascularization. Design. All the patients were sent a postal questionnaire for symptom evaluation. Setting. All hospitals in western Sweden. Subjects. All patients in western Sweden on the waiting list in September 1990, who had been referred for coronary angiography or revascularization (n = 904) and a sex- and age-matched reference group (n = 809). Results. More than half of the patients had daily attacks of chest pain, whereas 16% reported less than one attack per week or no pain at all. However, other symptoms such as dyspnoea, tachycardia and nervous reactions were also common and 25% of all patients used sedatives. A long waiting time for a given procedure was not associated with more pain but with more nervous symptoms such as restlessness and insomnia (P < 0.0001) and greater use of sedatives and cigarettes (P < 0.05). Conclusions. We conclude that a long waiting time for possible coronary revascularization is associated with more nervous symptoms but not with more pain.

  • 2. Berglin Blohm, M
    et al.
    Hartford, M
    Karlsson, T
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare. [external].
    Factors associated with prehospital and in-hospital delay time in acute myocardial infarction: a 6-year experience1998In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 243, no 3, p. 243-250Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: To explore factors associated with delay time prior to hospital admission and in hospital amongst acute myocardial infarction (AMI) patients with particular emphasis on the delay time to the administration of thrombolytic therapy. METHODS: During a 6-year period we prospectively computerized pre-hospital and in-hospital time intervals for AMI patients admitted to the coronary care unit (CCU) direct from the emergency department (ED) or via paramedics, at Sahlgrenska Hospital, Göteborg, Sweden. RESULTS: Pre-hospital delay: independent predictors of a prolonged delay were increased age (P = 0.0007), female sex (P = 0.02) and a history of hypertension (P = 0.03). For AMI patients who received thrombolytic treatment and the only independent predictor of a prolonged delay was increased age (P = 0.005). In-hospital delay: for all AMI patients independent predictors of a prolonged delay were prolonged pre-hospital delay (P < 0.0001), increased age (P = 0.03) and a history of angina (P = 0.002), hypertension (P = 0.01) and diabetes (P = 0.01). For thrombolytic treated AMI patients independent predictors of a prolonged delay were prolonged pre-hospital delay (P < 0.0001), female sex (P = 0.02) and a history of diabetes (P = 0.02). CONCLUSION: Risk factors for both pre-hospital and hospital delay time could in AMI be defined although slightly different. Two factors appeared for both, i.e. increasing age and a history of hypertension.

  • 3. Everts, B
    et al.
    Karlson, BW
    Abdon, N-J
    Herlitz, Johan
    [external].
    Hedner, T
    A comparison of metoprolol and morphine in the treatment of chest pain in patients with suspected acute myocardial infarction--the MEMO study1998In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 245, no 2, p. 133-141Article in journal (Refereed)
    Abstract [en]

    Objectives. To compare the analgesic effect of metoprolol and morphine in patients with chest pain due to suspected or definite acute myocardial infarction after initial treatment with intravenous metoprolol. Design. All patients, regardless of age, admitted to the coronary care unit at Uddevalla Central Hospital due to suspected acute myocardial infarction were evaluated for inclusion in the MEMO study (metoprolol–morphine). The effects on chest pain and side-effects of the two treatments were followed during 24 h. Pain was assessed by a numerical rating scale. Results. A total of 265 patients were randomized in this prospective double-blind study and 59% developed a confirmed acute myocardial infarction. In both treatment groups, there were rapid reductions of pain intensity. However, in the patient group treated with morphine, there was a more pronounced pain relief during the first 80 min after start of double-blind treatment. The side-effects were few and were those expected from each therapeutic regimen. During the first 24 h, nausea requiring anti-emetics was more common in the morphine-treated patients. Conclusion. In suspected acute myocardial infarction, if chest pain persists after intravenous beta-adrenergic blockade treatment, standard doses of an opioid analgesic such as morphine will offer better pain relief than increased dosages of metoprolol.

  • 4. From Attebring, M
    et al.
    Herlitz, Johan
    [external].
    Berndt, A-K
    Karlsson, T
    Hjalmarsson, A
    Are patients truthfull about their smoking habits? A validation of self-report about smoking cessation with biochemical markers of smoking activity amongst patients with ischaemic heart disease.2001In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 249, no 2, p. 145-151Article in journal (Refereed)
    Abstract [en]

    AIMS: To validate self-report about smoking cessation with biochemical markers of smoking activity amongst patients with ischaemic heart disease. PATIENTS AND METHODS: Outpatients at the Division of Cardiology, 75 years of age or younger, who had been Hospitalized at Sahlgrenska University Hospital in Göteborg due to an ischaemic event and who consecutively participated in a nurse-monitored routine care programme for secondary prevention, from 6 February 1997 to 5 February 1998. Data concerning smoking habits were collected through interviews. Two chemical markers, cotinine in plasma and carbon monoxide (CO) in expired air, validated self-reports concerning smoking cessation. RESULTS: 260 former smokers were validated. In the vast majority of the study population, the anamnestic information concurred with the chemical marker. However, 17 patients had chemical markers that contradicted their self-report with raised CO (n = 6) and/or raised cotinine levels (n = 13) without alternative nicotine delivery. CONCLUSION: Most patients with coronary artery disease relating information concerning cessation of smoking are truthful. A few patients, however, seem to conceal their smoking. Testing by chemical markers may be questionable for ordinary care but should, however, be included in studies concerning the association between smoking and health.

  • 5. Hartford, M
    et al.
    Herlitz, Johan
    [external].
    Karlsson, BW
    Risenfors, M
    Components of delay time in suspected acute myocardinal infarction with particular emphasis on patient delay1990In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 228, no 5, p. 519-523Article in journal (Refereed)
    Abstract [en]

    Two hundred and thirty-four patients admitted to a coronary care unit (CCU) were interviewed a few days after arrival in hospital to determine reasons for patient delay and the various components of total delay time from onset of symptoms to arrival in CCU. Of the three major components of delay, decision time (time from onset of symptoms to decision to go to hospital), and hospital procedure time (time from arrival in hospital to arrival in the CCU), were of the same magnitude, 1 h 15 min and 1 h 30 min (median), whereas the median time for preparation and transportation to hospital was somewhat shorter, being 45 min. Decision time appeared to be similar in patients with confirmed and non-confirmed acute myocardial infarction (AMI) and was not associated with intensity of pain or infarct size. Half of the patients hesitated to go to hospital, which resulted in a prolonged decision delay (3 h). It is concluded that patient indecision to seek medical help is the most important reason for delay in hospital arrival in patients with suspected AMI.

  • 6. Hartford, M
    et al.
    Wiklund, O
    Mattsson Hultén, L
    Persson, A
    Karlsson, T
    Herlitz, Johan
    [external].
    Caidahl, K
    C-reactive protein, interleukin-6, secretory phospholipase A2 group IIA and intercellular adhesion molecule-1 in the prediction of late outcome events after acute coronary syndromes.2007In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 262, no 5, p. 526-536Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: We investigated whether levels of C-reactive protein (CRP), interleukin-6 (IL-6), secretory phospholipase A(2) group IIA (sPLA(2)-IIA) and intercellular adhesion molecule-1 (ICAM-I) predict late outcomes in patients with acute coronary syndromes (ACS). DESIGN: Prospective longitudinal study. CRP (mg L(-1)), IL-6 (pg mL(-1)), sPLA(2)-IIA (ng mL(-1)) and ICAM-1 (ng mL(-1)) were measured at days 1 (n = 757) and 4 (n = 533) after hospital admission for ACS. Their relations to mortality and rehospitalization for myocardial infarction (MI) and congestive heart failure (CHF) were determined. SETTING: Coronary Care Unit at Sahlgrenska University Hospital, Gothenburg, Sweden. SUBJECTS: Patients with ACS alive at day 30; median follow-up 75 months. RESULTS: Survival was related to day 1 levels of all markers. After adjustment for confounders, CRP, IL-6 and ICAM-1, but not sPLA(2)-IIA, independently predicted mortality and rehospitalization for CHF. For CRP, the hazard ratio (HR) was 1.3 for mortality (95% confidence interval (CI): 1.1-1.5, P = 0.003) and 1.4 for CHF (95% CI: 1.1-1.9, P = 0.006). For IL-6, HR was 1.3 for mortality (95% CI: 1.1-1.6, P < 0.001) and 1.4 for CHF (95% CI: 1.1-1.8, P = 0.02). For ICAM-1, HR was 1.2 for mortality (95% CI: 1.0-1.4, P = 0.04) and 1.3 for CHF (95% CI: 1.0-1.7, P = 0.03). No marker predicted MI. Marker levels on day 4 provided no additional predictive value. CONCLUSIONS: In patients with ACS, CRP, IL-6, sPLA(2)-IIA and ICAM-1 are associated with long-term mortality and CHF, but not reinfarction. CRP, IL-6 and ICAM-1 provide prognostic information beyond that obtained by clinical variables.

  • 7.
    Herlitz, Johan
    [external].
    Long-term prognosis after early intervention tieh petoprolol in susptected acute myocardial infarction: experiences from the MIAMI Trial1991In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 230, no 3, p. 233-238Article in journal (Refereed)
    Abstract [en]

    A total of 5778 patients with suspected acute myocardial infarction were randomized to early intravenous metoprolol followed by oral treatment for 15 d, or to placebo. Thereafter, the two groups were treated similarly. During a 1-year follow-up period the mortality in patients who were randomized to early metoprolol was 10.6% compared to 10.7% for placebo (P greater than 0.2). Among patients with a higher risk of death, the tendency towards a reduced mortality in the metoprolol group that was observed after 15 d remained similar after 1 year. It is concluded that early intervention with metoprolol in suspected acute myocardial infarction did not improve the long-term prognosis compared to placebo treatment.

  • 8.
    Herlitz, Johan
    et al.
    [external].
    Brandrup-Wognsen, G
    Karlson, BW
    Sjöland, H
    Karlsson, T
    Caidahl, K
    Hartford, M
    Haglid, M
    Mortality, risk indicators for death, mode of death and symptoms of angina pectoris during 5 years after coronary artery bypass grafting in men and women2000In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 247, no 4, p. 500-506Article in journal (Refereed)
    Abstract [en]

    AIM: To describe mortality, risk indicators of death, mode of death and symptoms of angina pectoris during 5 years after coronary artery bypass grafting in women and men. SAMPLE: All patients in western Sweden who underwent coronary artery bypass grafting without concomitant valve surgery and without previously performed coronary artery bypass grafting between June 1988 and June 1991. RESULTS: In all, 2000 patients participated in the evaluation, 381 (19%) of whom were women. Compared to men, who had a 5-year mortality of 13.3%, women had a relative risk of death of 1.4 (95% CI 1.0-1.8; P = 0.03). Renal dysfunction interacted significantly (P = 0.048) with gender, in that the differences were more marked in patients without renal dysfunction. When adjusting for differences at baseline, the relative risk of death amongst women was 1.0 (95% CL 0.7-1.3). Compared to men, women had an increased risk of in-hospital death and death associated with stroke. However, amongst the patients who died, the place and mode of death appeared to be similar in women and men. Amongst survivors after 5 years, women had more symptoms of angina pectoris than men. CONCLUSION: During 5 years after coronary artery bypass grafting, women had an increased mortality compared to men; renal dysfunction seemed to interact with female gender regarding mortality. Women had a higher risk of in-hospital death and death associated with stroke. However, the adjusted relative risk of death during 5 years was equal in women and men. Amongst survivors, women suffered more from angina pectoris than men.

  • 9.
    Herlitz, Johan
    et al.
    [external].
    Brorsson, B
    Werkö, L
    Factors associated with the use of various medications among patients with severe coronary artery disease. SECOR/SBU Project Group.1999In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 245, no 2, p. 143-153Article in journal (Refereed)
    Abstract [en]

    Aim. To describe variations by age, sex, symptom severity and hospital region in the use of various medications amongst patients with stable angina pectoris who are candidates for coronary revascularization. Patients. Patients (n = 2030) with chronic stable angina pectoris participating in a national survey evaluating the appropriateness of the use of percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG). Methods. As part of a national study of the appropriateness of coronary revascularization, data were prospectively collected on patients referred for consideration of coronary revascularization to seven of the eight public Swedish heart centres that performed approximately 92% of all bypass operations in Sweden in 1994. Results. Amongst all patients 76% were treated with beta blockers, 41% with calcium antagonists and 71% with long-acting nitrates and 70% were treated with at least two of these three drugs. Eighty-two per cent of the patients used aspirin and 14% lipid-lowering drugs. According to logistic regression analysis, with medication as the dependent variable and independent variables of age, sex, angina functional class, findings at exercise test, history of various diseases and region in Sweden where the investigation took place, the most consistent factor explaining the use of various medications was found to be geographical region. A previous history of acute myocardial infarction (AMI) was also associated with the use of all drugs and age was associated with all with the exception of beta blockers. Sex was not an independent factor explaining the use of any of the drugs. Conclusion. In a national survey including patients with stable angina pectoris who are potential candidates for coronary revascularization, the most important predictor for the use of various medications was the geographical region in which the investigation took place.

  • 10.
    Herlitz, Johan
    et al.
    [external].
    Bång, A
    [external].
    Aune, S
    Ekström, L
    Lundström, G
    Holmberg, S
    Holmberg, M
    Lindqvist, J
    A comparison between patients suffering in-hospital and out-of-hospital cardiac arrest in terms of treatment and outcome2000In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 248, no 1, p. 53-60Article in journal (Refereed)
    Abstract [en]

    AIM: To compare treatment and outcome amongst patients suffering in-hospital and out-of-hospital cardiac arrest in the same community. PATIENTS: All patients suffering in-hospital cardiac arrest in Sahlgrenska University Hospital covering half the catchment area of the community of Göteborg (500 000 inhabitants) and all patients suffering out-of-hospital cardiac arrest in the community of Göteborg. Criteria for inclusion were that resuscitation efforts should have been attempted. TIME OF SURVEY: From 1 November 1994 to 1 November 1997. METHODS: Data were recorded both prospectively and retrospectively. RESULTS: In total, 422 patients suffered in-hospital cardiac arrest and 778 patients suffered out-of-hospital cardiac arrest. Patients with in-hospital cardiac arrest included more women and were more frequently found in ventricular fibrillation. The median interval between collapse and defibrillation was 2 min in in-hospital cardiac arrest compared with 7 min in out-of-hospital cardiac arrest (< 0.001). The proportion of patients being discharged from hospital was 37.5% after in-hospital cardiac arrest, compared with 8.7% after out-of-hospital cardiac arrest (P < 0.001). Corresponding figures for patients found in ventricular fibrillation were 56.9 vs. 19.7% (P < 0.001) and for patients found in asystole 25.2 vs. 1.8% (P < 0.001). CONCLUSION: In a survey evaluating patients with in-hospital and out-of-hospital cardiac arrest in whom resuscitation efforts were attempted, we found that the former group had a survival rate more than four times higher than the latter. Possible strong contributing factors to this observation are: (i) shorter time interval to start of treatment, and (ii) a prepared selection for resuscitation efforts.

  • 11.
    Herlitz, Johan
    et al.
    [external].
    Dellborg, M
    Hartford, M
    Karlsson, T
    Risenfors, M
    Karlsson, BW
    Luepker, R
    Holmberg, S
    Swedberg, K
    Hjalmarson, Å
    Mortality and morbidity 1 year after early thrombolysis in suspected AMI: results from the TEAHAT Study1991In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 734, no suppl 1, p. 43-51Article in journal (Refereed)
    Abstract [en]

    We randomized 352 patients with suspected acute myocardial infarction (AMI) to treatment with rt-PA (n = 177) or placebo (n = 175). Patients were eligible if evaluated within 2 h and 45 min from onset of chest pain, and if aged less than 75 years. There were no ECG criteria for inclusion. A mobile coronary-care unit with a cardiologist present was used to initiate treatment at home in 29% of cases. During 1 year of follow-up the mortality in patients treated with rt-PA was 10.2%, as compared with 14.3% in patients the initial ECG, the mortality during the first year was 8% in the rt-PA group vs. 18% in the placebo group (P less than 0.05). Among patients without ST-elevation the mortality was 9% for the rt-PA group vs. 12% for the placebo group (NS). Requirement for rehospitalization, symptoms of angina pectoris and congestive heart failure, time of return to work and requirement for various medications did not differ significantly between the two groups, regardless of the initial ECG pattern.

  • 12.
    Herlitz, Johan
    et al.
    [external].
    Hjalmarson, Å
    Waldenström, A
    Waagstein, F
    Relationship between enzymatically estimated infarct size and short- and long-term survival after acute myocardial infarction1984In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 216, no 3, p. 261-267Article in journal (Refereed)
    Abstract [en]

    In 585 patients with acute myocardial infarction (AMI) and no previous MI the maximal activity of serum heat-stable lactate dehydrogenase (LD) (EC 1.1.1.27) activity was related to 1-year and 2-year mortality rates. All patients participated in a double-blind trial with metoprolol during the first three months after an AMI. Thereafter both groups were treated in a similar way. A strong relationship was found between LD maximum activity and the in-hospital prognosis (p<0.001), the 1-year survival rate (p<0.001) and the 2-year survival rate (p<0.001). When the patients who were alive after primary hospitalization were analyzed as a separate group, the relationship between LD maximum activity and 1-year and 2-year survival rates remained (p<0.001). In a subsample of 171 patients the maximal activity of creatine kinase (CK) (EC 2.7.3.2) and CK subunit B did not correlate either with in-hospital, 1-year or 2-year survival rates. We conclude that, when a sufficiently large number of patients are investigated, there is a strong relationship between serum enzyme maximum activity and short- and long-term survival.

  • 13.
    Herlitz, Johan
    et al.
    [external].
    Holm, J
    Petersson, M
    Karlson, BW
    Haglid Evander, M
    Erhardt, L
    Factors associated with development of stroke long-term after myocardial infarction: experiences from the LoWASA trial2005In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 257, no 2, p. 201-207Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To describe factors associated with the development of stroke during long-term follow-up after acute myocardial infarction (AMI) in the LoWASA trial. PATIENTS: Patients who had been hospitalized for AMI were randomized within 42 days to receive either warfarin 1.25 mg plus aspirin 75 mg daily or aspirin 75 mg alone. DESIGN: The study was performed according to the probe design, that is open treatment and blinded end-point evaluation. SETTING: The study was performed in 31 hospitals in Sweden. The mean follow-up time was 5.0 years with a range of 1.7-6.7 years. RESULTS: In all, 3300 patients were randomized in the trial, of which 194 (5.9%) developed stroke (4.2% nonhaemorrhagic, 0.5% haemorrhagic and 1.3% uncertain. The following factors appeared as independent predictors for an increased risk of stroke: age, hazard ratio and 95% confidence interval (1.07; 1.05-1.08), a history of diabetes mellitus (2.4; 1.8-3.4), a history of stroke (2.3; 1.5-3.5), a history of hypertension (2.0; 1.5-2.7) and a history of smoking (1.5;1.1-2.0). Most of these factors were also predictors of a nonhaemorrhagic stroke whereas no predictor of haemorrhagic stroke was found. CONCLUSION: Risk indicators for stroke long-term after AMI were increasing age, a history of either diabetes mellitus, stroke, hypertension or smoking.

  • 14.
    Herlitz, Johan
    et al.
    [external].
    Karlson, BW
    Lindqvist, J
    Sjölin, M
    Predictors and mode of death over 5 years amongst patients admitted to the emergency department with acute chest pain or other symptoms raising suspicion of acute myocardial infarction1997In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 243, no 1, p. 41-48Article in journal (Refereed)
    Abstract [en]

    AIM: To describe the mortality and mode of death over 5 years, and factors associated with death amongst patients with acute chest pain. PATIENTS: All patients who came to the emergency department at Sahlgrenska Hospital in Göteborg with acute chest pain or other symptoms raising suspicion of acute myocardial infarction (AMI) during a 21-month period. RESULTS: In all, 5241 patients were evaluated, of whom 1345 (26%) died during the 5 years of follow-up. The following factors were independent predictors male sex (P < 0.001); symptoms of acute congestive heart failure (P < 0.001) or unspecific symptoms on admission (P < 0.05); smoking (P < 0.001); a history of either congestive heart failure (P < 0.001), diabetes mellitus (P < 0.001), previous myocardial infarction (P < 0.001) or hypertension (P < 0.05); initial degree of suspicion of AMI (P < 0.001) and presence of pathological electrocardiogram (P < 0.001) on admission to hospital. Amongst patients who died, 66% died a cardiac death and 35% died in association with a myocardial infarction. CONCLUSION: Amongst patients admitted to the emergency department due to chest pain or other symptoms raising suspicion of AMI, several predictors based on clinical history and clinical presentation can be defined, which are strongly related to the long-term prognosis.

  • 15.
    Herlitz, Johan
    et al.
    [external].
    Karlson, BW
    Sjölin, M
    Lindqvist, J
    Ten year mortality for patients discharged after hospitalization for chest pain or other symptoms raising suspicion of acute myocardial infarction in relation to hospital discharge diagnosis2002In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 251, no 6, p. 526-253Article in journal (Refereed)
    Abstract [en]

    Keywords: mortality; myocardial infarction; myocardial ischaemia; prognosis Abstract. Herlitz J, Karlson BW, Sjölin M, Lindqvist J (Sahlgrenska University Hospital, Göteborg, Sweden). Ten-year mortality for patients discharged after hospitalization for chest pain or other symptoms raising suspicion of acute myocardial infarction in relation to hospital discharge diagnosis. J Intern Med 2002; 251: 526–532. Aim. To describe the 10-year prognosis for patients discharged after hospitalization for chest pain or other symptoms giving an initial suspicion of acute myocardial infarction (AMI) in relation to the final hospital diagnosis and furthermore to compare the outcome amongst these patients with the outcome amongst a sex-, age- and community-matched con- trol population. Methods. All patients who were hospitalized because of chest pain or other symptoms raising a suspicion of AMI and who were discharged alive from hospital. Patients were divided into three groups according to the final diagnosis: (1) confirmed or possible AMI, (2) confirmed or possible myocardial ischaemia and (3) other aetiology. Information on 10-year mortality was available in 3103 patients. A sex-, age- and community-matched control population (n=3221) was compared with the study population in terms of 10-year mortality. Time of the survey. 15 February 1986 to 9 November 1987. Setting. Sahlgrenska University Hospital. Results. Patients with confirmed or possible AMI (n=849) had a significantly higher mortality (59.4%) than patients with confirmed or possible myocardial ischaemia (n=1191) who had a mortality of 49.5% (P < 0.0001). The latter group had a higher mortality than patients with `other aetiology' (n=1063) of whom 40.6% died (P < 0.0001). When comparing the prognosis for patients with AMI and myocardial ischaemia, there was a significant interaction with sex, with a more marked difference in women than in men. Amongst all patients, the 10-year mortality was 49.1 vs. 37.3% in the control group (P < 0.0001). Conclusion. The very long term prognosis was strongly associated with diagnosis amongst patients hospitalized and discharged alive because of chest pain or other symptoms raising suspicion of AMI. The absolute mortality difference between patients who were discharged from hospital with confirmed diagnosis of AMI and those whose symptoms were considered to have other aetiology than AMI or ischaemia was nearly 20%. However, the absolute mortality difference between the patients included in the survey and a control population was only 12%.

  • 16.
    Herlitz, Johan
    et al.
    [external].
    Karlsson, BW
    Hjalmarson, Å
    Mortality and morbidity during one year of follow-up in suspected acute myocardial infarction in relation to early diagnosis: experiences from the MIAMI trial1990In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 228, no 2, p. 125-131Article in journal (Refereed)
    Abstract [en]

    From a large randomized multicentre trial of metoprolol in suspected acute myocardial infarction (n = 5778) we report on the outcome during 1 year of follow-up, in relation to early diagnosis. Patients who developed a confirmed infarction had a 1-year mortality rate of 12.8%. This was significantly higher than the mortality rate of 6.3% (P less than 0.001) in patients with possible infarction and it was also higher than that in patients with no infarction, which was 5.0% (P less than 0.001). A multivariate analysis showed that independent risk predictors in the clinical history of patients without confirmed infarction were a history of angina pectoris, chronic use of digitalis and advanced age. After 1 year, angina pectoris was most common in patients with an initial possible infarction. These patients were also in most urgent need of bypass surgery. We thus conclude that the mortality during 1 year of follow-up among patients with an initially strongly suspected acute myocardial infarction was clearly related to whether or not the patient developed a myocardial infarction.

  • 17.
    Herlitz, Johan
    et al.
    [external].
    Malmberg, K
    Karlsson, BW
    Ståhl, L
    Rydén, L
    Hjalmarson, Å
    Mortality and morbidity during a five-year follow-up of diabetics with myocardial infarction1988In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 224, no 1, p. 31-38Article in journal (Refereed)
    Abstract [en]

    In 787 patients with acute myocardial infarction originally participating in the Göteborg Metoprolol Trial, mortality and morbidity during 5 years' follow-up were assessed and related to whether patients had diabetes mellitus. Diabetes occurred in 78 patients (10%). Patients with diabetes had a different risk factor pattern, including higher age, higher occurrence of angina pectoris and hypertension, whereas smoking habits did not differ. In the early phase (hospitalization), patients with diabetes had a higher mortality (12% versus 8%), required more treatment for heart failure and stayed longer in hospital. Other morbidity aspects, such as severity of pain, occurrence of severe supraventricular and ventricular arrhythmias, high-degree AV-block and infarct size did not differ. During 5 years' follow-up mortality rate in patients with diabetes mellitus was 55% as compared with 30% among patients with no diabetes (P<0.001). Reinfarction rate during 5 years was 42% in daibetics versus 25% in non-diabetics (P<0.001). In a multivariate analysis, taking into account the differences in risk factor pattern, diabetes turned out to be an independent determinant for long-term mortality and reinfarction (P<0.001). We conclude that patients with diabetes mellitus, developing acute myocardial infarction, is a group with particularly high risk of death and reinfarction. Interventions aiming at its reduction have priority.

  • 18.
    Herlitz, Johan
    et al.
    [external].
    Svensson, L
    Silfverstolpe, J
    Ängquist, K-A
    Wisten, A
    Engdahl, J
    Holmberg, S
    Characteristics and outcome amongst young adults suffering from out-of-hospital cardiac arrest in whom cardiopulmonary resuscitation is attempted.2006In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 260, no 5, p. 435-441Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: Amongst patients suffering from out-of-hospital cardiac arrest, young adults represent a minority. However, these victims suffer from the catastrophe when they are in a very active phase of life and have a long life expectancy. This survey aims to describe young adults in Sweden who suffer from out-of-hospital cardiac arrest and in whom cardiopulmonary resuscitation (CPR) is attempted in terms of characteristics and outcome. DESIGN: Prospective and descriptive design. SUBJECTS AND METHODS: Young adults (18-35 years) who suffered from out-of-hospital cardiac arrest in whom CPR was attempted and who were included in the Swedish Cardiac Arrest Registry between 1990 and 2004. MAIN OUTCOME MEASURES: Survival to 1 month. RESULTS: In all, 1105 young adults (3.1% of all the patients in the registry) were included, of which 29% were females, 51% were nonwitnessed and 15% had a cardiac aetiology. Only 17% were found in ventricular fibrillation, 53% received bystander CPR. The overall survival to 1 month was 6.3%. High survival was found amongst patients found in ventricular fibrillation (20.8%) and those with a cardiac aetiology (14.8%). Ventricular fibrillation at the arrival of the rescue team remained an independent predictor of an increased chance of survival (odds ratio: 7.43; 95% confidence interval: 3.44-16.65). CONCLUSION: Amongst young adults suffering from out-of-hospital cardiac arrest and in whom CPR was attempted, a minority survived to 1 month. Subgroups with a higher survival could be defined (patients found in ventricular fibrillation and patients in whom there was a cardiac aetiology). However, only one independent predictor of an increased chance of survival could be demonstrated, i.e. ventricular fibrillation at the arrival of the rescue team

  • 19. Hollenberg, J
    et al.
    Bång, Angela
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Lindqvist, J
    Herlitz, Johan
    [external].
    Nordlander, R
    Svensson, L
    Rosenqvist, M
    Difference in survival after out-of-hospital cardiac arrest between the two largest cities in Sweden: a matter of time?2005In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 257, no 3, p. 247-254Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Dramatic differences in survival after out-of-hospital cardiac arrests (OHCA) reported from different geographical locations require analysis. We therefore compared patients with OHCA in the two largest cities in Sweden with regard to various factors at resuscitation and outcome. SETTING: All patients suffering an OHCA in Stockholm and Goteborg between 1 January 2000 and 30 June 2001, in whom cardiopulmonary resuscitation (CPR) was attempted were included in this retrospective analysis. RESULTS: All together, 969 OHCA in Stockholm and 398 in Goteborg were registered during the 18-month study period. There were no differences in terms of age, gender, and percentage of witnessed cases or percentage of patients who had received bystander CPR. However, the percentage of patients with ventricular fibrillation (VF) at arrival of the ambulance crew was 18% in Stockholm versus 31% in Goteborg (P <0.0001). The percentage of patients who were alive 1 month after cardiac arrest was 2.5% in Stockholm versus 6.8% in Goteborg (P=0.0008). Various time intervals such as cardiac arrest to calling for an ambulance, cardiac arrest to the start of CPR and calling for an ambulance to its arrival were all significantly longer in Stockholm than in Goteborg. CONCLUSION: Survival was almost three times higher in Goteborg than in Stockholm amongst patients suffering an OHCA. This is primarily explained by a higher occurrence of VF at the time of arrival of the ambulance crew, which in turn probably is explained by shorter delays in Goteborg. The reason for the difference in time intervals is most likely multifactorial, with a significantly higher ambulance density in Goteborg as one possible explanation.

  • 20. Hollenberg, J
    et al.
    Bång, Angela
    Lindqvist, J
    Herlitz, Johan
    Norlander, R
    Svensson, L
    Rosenqvist, M
    Difference in survival after out-of-hospital cardiac arrest between the two largest cities in Sweden: a matter of time2005In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 257, no 3, p. 247-254Article in journal (Refereed)
    Abstract [en]

    Background.  Dramatic differences in survival after out-of-hospital cardiac arrests (OHCA) reported from different geographical locations require analysis. We therefore compared patients with OHCA in the two largest cities in Sweden with regard to various factors at resuscitation and outcome. Setting.  All patients suffering an OHCA in Stockholm and Göteborg between 1 January 2000 and 30 June 2001, in whom cardiopulmonary resuscitation (CPR) was attempted were included in this retrospective analysis. Results.  All together, 969 OHCA in Stockholm and 398 in Göteborg were registered during the 18-month study period. There were no differences in terms of age, gender, and percentage of witnessed cases or percentage of patients who had received bystander CPR. However, the percentage of patients with ventricular fibrillation (VF) at arrival of the ambulance crew was 18% in Stockholm versus 31% in Göteborg (P < 0.0001). The percentage of patients who were alive 1 month after cardiac arrest was 2.5% in Stockholm versus 6.8% in Göteborg (P = 0.0008). Various time intervals such as cardiac arrest to calling for an ambulance, cardiac arrest to the start of CPR and calling for an ambulance to its arrival were all significantly longer in Stockholm than in Göteborg. Conclusion.  Survival was almost three times higher in Göteborg than in Stockholm amongst patients suffering an OHCA. This is primarily explained by a higher occurrence of VF at the time of arrival of the ambulance crew, which in turn probably is explained by shorter delays in Göteborg. The reason for the difference in time intervals is most likely multifactorial, with a significantly higher ambulance density in Göteborg as one possible explanation.

  • 21. Karlson, BW
    et al.
    Wiklund, O
    Hallgren, P
    Sjölin, M
    Lindqvist, J
    Herlitz, Johan
    [external].
    Ten year mortality among patients with a very small or non-confirmed acute myocardial infarction in relation to clinical history, metabolic screening and signs of myocardial ischemia2000In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 247, no 4, p. 449-456Article in journal (Refereed)
    Abstract [en]

    Abstract. Karlson BW, Wiklund O, Hallgren P, SjoÈlin M, Lindqvist J, Herlitz J (Sahlgrenska University Hospital, GoÈteborg, Sweden). Ten-year mortality amongst patients with a very small or unconfirmed acute myocardial infarction in relation to clinical history, metabolic screening and signs of myocardial ischaemia. J Intern Med 2000; 247: 449±456. Aim. To evaluate the long-term prognosis amongst patients with a very small or unconfirmed acute myocardial infarction (AMI) in relation to clinical history, metabolic screening and signs of myocardial ischaemia at exercise test. Methods. Patients with a very small or unconfirmed AMI, aged , 76 years, were selected and given a clinical evaluation, metabolic screening and checked for ischaemia at an exercise test 4 weeks after admittance. The 10-year mortality was related to age, sex, clinical history, body weight, serum (S) cholesterol, S-triglycerides, S-gammaglutamyltranspeptidase (GT), S-glucose and various indices of myocardial ischaemia at exercise test. Results. In all, 714 patients participated in the evaluation. The median age was 63 years and 33% werewomen. The overall 10-year mortality was 33%. In univariate analysis, the following factors appeared as risk indicators for death: age (P , 0.0001), a history of previous AMI (P , 0.0001), angina pectoris (P , 0.001), diabetes mellitus (P , 0.0001), congestive heart failure (P , 0.0001), smoking (P = 0.030), S-triglycerides (P , 0.0001), S-gamma GT (P , 0.0001) and Sglucose (P , 0.0001). In multivariate analysis, the following remained as independent risk indicators for death: age (P , 0.0001), S-gamma GT (P , 0.0001), previous AMI (P , 0.0001), smoking (P , 0.0001) and Sglucose (P = 0.010). Conclusion. Amongst patients with a very small or a unconfirmed AMI, factors reflecting their clinical history, including age, a history of AMI and current smoking, as well as factors reflecting their metabolic status, including S-gamma GT and S-glucose, were important predictors for the long-term outcome.

  • 22. Karlsson, BW
    et al.
    Herlitz, Johan
    [external].
    Pettersson, P
    Ekvall, H-E
    Hjalmarson, Å
    Patients admitted to the emergency room with symptoms indicative of acute myocardial infarction1991In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 230, no 3, p. 251-258Article in journal (Refereed)
    Abstract [en]

    All 7157 patients (55% men) admitted to the emergency room with chest pain or other symptoms indicative of acute myocardial infarction during a period of 21 months were registered consecutively. Chest pain was reported by 93% of the patients. On the basis of history, clinical examination, and electrocardiogram in the emergency room, all patients were prospectively classified in one of four categories: (i) obvious infarction (4% of all patients): (ii) strongly suspected infarction (20%): (iii) vague suspicion of infarction (35%); and (iv) no suspected infarction (41%). In patients with no suspected infarction (n = 2910), musculoskeletal (26%), obscure (21%) and psychogenic origins (16%) of the symptoms occurred most frequently. We conclude that few of the patients had an obvious infarction on admission, and that a musculoskeletal origin of the symptoms occurred most frequently in patients with no suspected infarction.

  • 23. Lundstam, U
    et al.
    Herlitz, Johan
    [external].
    Karlsson, T
    Linden, T
    Wiklund, O
    Serum lipids, lipoprotein(a) level, and apolipoprotein(a) isoforms as prognostic markers in patients with coronary heart disease.2002In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 251, no 2, p. 111-118Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: Our objective was to study prognostic factors for death in patients with coronary heart disease (CHD), focusing on serum lipids and lipoproteins. DESIGN AND SUBJECTS: The study subjects were 964 patients with angina pectoris who underwent coronary angiography between 1985 and 1987. Follow-up, including survival and cause of death, was carried out in April 1998. RESULTS: A total of 363 patients died. Increasing age, diabetes and low levels of HDL cholesterol and of apolipoprotein (apo) AI were associated with increased risk of total mortality and cardiac mortality. In men, low levels of LDL cholesterol and of apoB were associated with increased risk of death, but not of cardiac death only; high levels of lipoprotein(a) [Lp(a)] were not associated with increased risk. In women, however, there was a trend towards increased risk with increasing Lp(a) levels (P = 0.054); the smallest isoform of apo(a) was associated with a twofold increase in risk. In women, but not in men, risk decreased with increasing molecular weight of the apo(a) isoforms. CONCLUSIONS: Amongst lipoprotein variables, low levels of HDL cholesterol and of apoAI and the presence of low-molecular weight isoforms of apo(a) are associated with increased risk of death in patients with CHD. Apo(a) isoforms and Lp(a) levels seem to be more important as risk factors amongst women. Low LDL cholesterol and apoB levels were associated with increased risk, but only in men. These findings demonstrate the importance of a gender-specific analysis of risk factors for CHD.

  • 24.
    Ringh, M
    et al.
    Department for Medicine, Center for Resuscitation Science, Karolinska Institutet.
    Hollenberg, J
    Department for Medicine, Center for Resuscitation Science, Karolinska Institutet.
    Palsgaard-Moeller, T
    Emergency Medical Services Copenhagen, University of Copenhagen.
    Svensson, L
    Department for Medicine, Center for Resuscitation Science, Karolinska Institutet.
    Rosenqvist, M
    Department for Medicine, Center for Resuscitation Science, Karolinska Institutet.
    Lippert, F K
    Emergency Medical Services Copenhagen, University of Copenhagen.
    Wissenberg, M
    Emergency Medical Services Copenhagen, University of Copenhagen.
    Malta Hansen, C
    Emergency Medical Services Copenhagen, University of Copenhagen.
    Claesson, A
    Department for Medicine, Center for Resuscitation Science, Karolinska Institutet.
    Viereck, S
    Emergency Medical Services Copenhagen, University of Copenhagen.
    Zijlstra, J A
    Department of Cardiology, Heart Center, Academic Medical Center.
    Koster, R W
    Department of Cardiology, Heart Center, Academic Medical Center.
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Blom, M T
    Department of Cardiology, Heart Center, Academic Medical Center.
    Kramer-Johansen, J
    Department of Anaesthesiology Oslo University Hospital and University of Oslo.
    Tan, H L
    Department of Cardiology, Heart Center, Academic Medical Center.
    Beesems, S G
    Department of Cardiology, Heart Center, Academic Medical Center,.
    Hulleman, M
    Department of Cardiology, Heart Center, Academic Medical Center.
    Olasveengen, T M
    Department of Anaesthesiology Oslo University Hospital and University of Oslo.
    Folke, F
    Emergency Medical Services Copenhagen, University of Copenhagen.
    The challenges and possibilities of public access defibrillation.2018In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 283, no 3, p. 238-256Article in journal (Refereed)
    Abstract [en]

    Out-of-hospital cardiac arrest (OHCA) is a major health problem that affects approximately four hundred and thousand patients annually in the United States alone. It is a major challenge for the emergency medical system as decreased survival rates are directly proportional to the time delay from collapse to defibrillation. Historically, defibrillation has only been performed by physicians and in-hospital. With the development of automated external defibrillators (AEDs), rapid defibrillation by nonmedical professionals and subsequently by trained or untrained lay bystanders has become possible. Much hope has been put to the concept of Public Access Defibrillation with a massive dissemination of public available AEDs throughout most Western countries. Accordingly, current guidelines recommend that AEDs should be deployed in places with a high likelihood of OHCA. Despite these efforts, AED use is in most settings anecdotal with little effect on overall OHCA survival. The major reasons for low use of public AEDs are that most OHCAs take place outside high incidence sites of cardiac arrest and that most OHCAs take place in residential settings, currently defined as not suitable for Public Access Defibrillation. However, the use of new technology for identification and recruitment of lay bystanders and nearby AEDs to the scene of the cardiac arrest as well as new methods for strategic AED placement redefines and challenges the current concept and definitions of Public Access Defibrillation. Existing evidence of Public Access Defibrillation and knowledge gaps and future directions to improve outcomes for OHCA are discussed. In addition, a new definition of the different levels of Public Access Defibrillation is offered as well as new strategies for increasing AED use in the society.

  • 25. Risenfors, M
    et al.
    Gustavsson, G
    Ekström, L
    Hartford, M
    Herlitz, Johan
    [external].
    Karlsson, BW
    Luepker, R
    Swedberg, K
    Wennerblom, B
    Holmberg, S
    Prehospital thrombolysis in suspected acute myocardial infarction: results from the TEAHAT Study1991In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 734, no suppl 1, p. 3-10Article in journal (Refereed)
    Abstract [en]

    Prehospital thrombolysis in suspected acute myocardial infarction: results from the TEAHAT Study

  • 26. Risenfors, M
    et al.
    Hartford, M
    Dellborg, M
    Edvardsson, N
    Emanuelsson, H
    Karlsson, BW
    Sandstedt, B
    Herlitz, Johan
    [external].
    Effects on chest pain of early thrombolytic treatment in suspected acute myocardial infarction: results from the TEAHAT Study1991In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 734, no suppl 1, p. 27-34Article in journal (Refereed)
    Abstract [en]

    In a randomized, double-blind study, in which recombinant tissue plasminogen activator (rt-PA) administered at an early stage was compared with placebo in patients with suspected acute myocardial infarction (AMI), the effects on pain were studied in 312 patients. Inclusion criteria were as follows: (a) chest pain of duration less than 2 h and 45 min; and (b) age less than 75 years. Chest pain was estimated subjectively by the patients, using a 10-point numerical rating scale, at hourly intervals for the first 24 h, and by the requirement for narcotic analgesics. Compared with placebo, rt-PA treatment resulted in a 43% reduction in mean total pain score (P less than 0.0001), a 26% reduction in pain duration (P less than 0.01), and a 33% reduction in morphine requirement (P = 0.01). Fifty-seven per cent of all patients developed a confirmed AMI. In these subjects rt-PA reduced the pain score by 46% (P less than 0.001). Among patients without confirmed AMI, a 37% reduction in pain score was observed (P = 0.05). The effect on pain was most marked in patients with ST-elevation on the initial ECG. We conclude that early treatment with rt-PA in suspected AMI reduces chest pain considerably. The effect is most marked in patients with ST-elevation on the initial ECG.

  • 27. Risenfors, M
    et al.
    Hartford, M
    Dellborg, M
    Luepker, R
    Hjalmarson, Å
    Swedberg, K
    Holmberg, S
    Herlitz, Johan
    [external].
    Effect on early intravenous rt-PA on infarct size estimated from serum enzyme activity: results from the TEAHAT Study1991In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 734, no suppl 1, p. 11-18Article in journal (Refereed)
    Abstract [en]

    In 319 patients who participated in a double-blind trial to evaluate the effect of early rt-PA administration compared to placebo in suspected acute myocardial infarction, infarct size was assessed from analyses of serum activity of lactate dehydrogenase isoenzyme 1 (LD 1). Treatment was always started less than 3 h after the onset of symptoms, with one-third of the patients' treatment being initiated outside the hospital. The maximum activity of LD 1 was reduced by 32%, from 13.3 mu kat l-1 in placebo to 9.0 mu kat l-1 in rt-PA treated patients (P = 0.001). A reduction in LD-1 activity after rt-PA treatment was restricted to patients with ST-elevation in the initial electrocardiogram, and was more pronounced in patients with previous ischaemic heart disease, above median age, and in those with a shorter delay in initiation of treatment. We conclude that very early intravenous treatment with rt-PA limits indirect signs of infarct size. The effect appears to be restricted to patients with ST-segment elevation in their initial electrocardiogram.

  • 28. Risenfors, M
    et al.
    Herlitz, Johan
    [external].
    Bergh, C-H
    Dellborg, M
    Gottfridsson, C
    Gustavsson, G
    Lomsky, M
    Swedberg, K
    Hjalmarson, Å
    Early treatment with thrombolysis and betablockade in suspected acute myocardial infarction: results from the TEAHAT Study1991In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 734, no suppl 1, p. 35-42Article in journal (Refereed)
    Abstract [en]

    Independent trials of early administration of beta-blockers and thrombolytic agents have shown beneficial effects on both short- and long-term prognoses in acute myocardial infarction (AMI). The effects of a combination of the two strategies have not been thoroughly documented. Three hundred and fifty-two patients, of less than 75 years of age, with chest pain indicative of AMI, and onset less than 2 h and 45 min before first examination, were randomized to treatment with rt-PA or placebo. All patients without contraindication were given intravenous metoprolol 15 mg acutely and then 200 mg orally daily. Treatment was started either at the prehospital stage or in hospital. Thirty-seven per cent of patients had contraindications to beta-blockade, the most frequent of which were heart rate less than 60 beats min-1 and hypotension. The remaining 63% were given intravenous beta-blockade. No side-effects of metoprolol, alone or in combination with rt-PA, were observed during the prehospital phase. Overall, toleration of the treatment was good. Reduction in enzymatically estimated infarct size by rt-PA was more pronounced in patients who were also treated with metoprolol (41%, P less than 0.001) than in those with contraindications to beta-blockade (15%, NS). Patients who were also treated with metoprolol also had a lower incidence of Q-wave infarctions, congestive heart failure and ventricular fibrillation than those who were not given intravenous beta-blockade. In conclusion, toleration of intravenous administration of rt-PA and metoprolol was good, and this was also the case in the prehospital phase.

  • 29. Risenfors, M
    et al.
    Zukauskiene, I
    Albertsson, P
    Hartford, M
    Lomsky, M
    Herlitz, Johan
    [external].
    Early thrombolytic therapy in suspected acute myocardial infarction: role of the electrocardiogram: results from the TEAHAT Study1991In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 734, no suppl 1, p. 19-25Article in journal (Refereed)
    Abstract [en]

    In a placebo-controlled trial in which rt-PA was administered to patients within 2 h and 45 min after the onset of symptoms indicative of acute myocardial infarction (AMI), 352 patients were randomized. Standard 12-lead electrocardiograms (ECGs) were recorded at inclusion and repeatedly during admission and at follow-up after 1 month and 1 year. In patients who presented with ST-segment elevation, the infarction rate was high (88%), whereas in patients without ST-elevation the infarction rate was low (21%), and infarct size, as assessed by serum enzyme activities, was small in this group. There were only minor differences between rt-PA- and placebo-treated patients with regard to ST-segment changes and Q-wave development, whereas the R-wave amplitude was higher after 1 month in patients who were given rt-PA. The infarction rate was not altered by rt-PA, but there was a shift towards a reduction in Q-wave infarction in patients who were treated with rt-PA. When a score system, as suggested by Palmeri et al., intended to reflect the ultimate infarct size, was applied, a significantly lower score was found in infarction patients who were treated with rt-PA as compared to placebo (3.95 +/- 0.35 vs. 2.95 +/- 0.29, P = 0.03), indicating limitation of infarct size. In summary, early treatment with rt-PA resulted in less frequent Q-wave infarction and a reduction in the electrocardiographically estimated infarct size.

  • 30. Sjöland, M
    et al.
    Wiklund, I
    Caidahl, K
    Hartford, M
    Karlsson, T
    Herlitz, Johan
    [external].
    Improvement in quality of life differs between women and men after coronary artery bypass surgery1999In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 245, no 5, p. 445-454Article in journal (Refereed)
    Abstract [en]

    Abstract. Sjöland H, Wiklund I, Caidahl K, Hartford M, Karlsson T, Herlitz J (Sahlgrenska University Hospital, Göteborg, and Astra Hässle AB, Mölndal, Sweden). Improvement in quality of life differs between women and men after coronary artery bypass surgery. J Intern Med 1999; 245: 445–454. Objective. To study improvement in quality of life (QoL) after coronary artery bypass grafting (CABG) in relation to gender. Background. Women generally report worse QoL after CABG than men. However, women are older and more symptomatic prior to surgery, which should be considered in comparative analyses. Methods. We studied consecutive patients who underwent CABG between 1988 and 1991 [n = 2121] with a QoL questionnaire containing the Physical Activity Score, the Nottingham Health Profile and the Psychological General Well-being Index prior to, 3 months, 1 year and 2 years after surgery. Results. Females were older than men with more concomitant diseases preoperatively. QoL was improved on all postoperative occasions for both sexes. Improvement in the Physical Activity Score was somewhat, although not significantly, greater in males. Improvement in the Nottingham Health Profile was greater in females. General well-being showed no consistent pattern for improvement. Conclusions. QoL is significantly improved after CABG in both sexes throughout follow-up. There is a complex association between improvement in various aspects of QoL and gender.

  • 31. Skrifvars, MB
    et al.
    Castrén, M
    Nurmi, J
    Thorén, A-B
    Aune, S
    Herlitz, Johan
    [external].
    Do patient characteristics or factors at resuscitation influence long-term outcome in patients surviving to be discharged following in-hospital cardiac arrest?2007In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 262, no 4, p. 488-495Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: Few studies have focused on factors influencing long-term outcome following in-hospital cardiac arrest. The present study assesses whether long-term outcome is influenced by difference in patient factors or factors at resuscitation. METHODS: An analysis of cardiac arrest data collected from one Swedish tertiary hospital and from five Finnish secondary hospitals supplemented with data on 1 year survival. Multiple logistic regression analysis was used to identify factors associated with survival at 12 months. RESULTS: A total of 441 patients survived to hospital discharge following in-hospital cardiac arrest and 359 (80%) were alive at 12 months. Factors independently associated with survival [odds ratio (OR) >1 indicates increased survival and <1 decreased survival] at 12 months were; age [OR 0.95, 95% confidence interval (CI) 0.93-0.98], renal disease (OR 0.3, CI 0.1-0.9), good functional status at discharge (OR 4.9, CI 1.3-18.9), arrest occurring at (compared with arrests on general wards) emergency wards (OR 4.7, CI 1.4-15.3), cardiac care unit (OR 2.8, CI 1.2-6.4), intensive care unit (OR 2.4, CI 1.1-5.7), ward for thoracic surgery (OR 10.2, CI 2.6-40.1) and unit for interventional radiology (OR 13.3, CI 3.4-52.0). There was no difference in initial rhythm, delay to defibrillation or delay to return of spontaneous circulation between survivors and nonsurvivors. CONCLUSION: Several patient factors, mainly age, functional status and co-morbid disease, influence long-term survival following cardiac arrest in hospital. The location where the arrest occurred also influences survival, but initial rhythm, delay to defibrillation and to return of spontaneous circulation do not.

  • 32. Strömsöe, A
    et al.
    Afzelius, S
    Axelsson, C
    University of Borås, School of Health Science.
    Södersved Kallestedt, ML
    Enlund, M
    Svensson, L
    Herlitz, J
    University of Borås, School of Health Science.
    Improvements in logistics could increase survival after out-of-hospital cardiac arrest in Sweden.2013In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 273, no 6, p. 622-7Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: In a review based on estimations and assumptions, to report the estimated number of survivors after out-of-hospital cardiac arrest (OHCA) in whom cardiopulmonary resuscitation (CPR) was started and to speculate about possible future improvements in Sweden. DESIGN: An observational study. SETTING: All ambulance organisations in Sweden. SUBJECTS: Patients included in the Swedish Cardiac Arrest Registry who suffered an OHCA between January 1, 2008 and December 31, 2010. Approximately 80% of OHCA cases in Sweden in which CPR was started are included. INTERVENTIONS: None RESULTS: In 11 005 patients, the 1-month survival rate was 9.4%. There are approximately 5000 OHCA cases annually in which CPR is started and 30-day survival is achieved in up to 500 patients yearly (6 per 100 000 inhabitants). Based on findings on survival in relation to the time to calling for the Emergency Medical Service (EMS) and the start of CPR and defibrillation, it was estimated that, if the delay from collapse to (i) calling EMS, (ii) the start of CPR, and (iii) the time to defibrillation were reduced to <2 min, <2 min, and <8 min, respectively, 300-400 additional lives could be saved. CONCLUSION: Based on findings relating to the delay to calling for the EMS and the start of CPR and defibrillation, we speculate that 300-400 additional OHCA patients yearly (4 per 100 000 inhabitants) could be saved in Sweden.

  • 33. Svensson, L
    et al.
    Axelsson, C
    [external].
    Nordlander, R
    Herlitz, Johan
    [external].
    Elevation of biochemical markers for myocardial damage prior to hospital admission in patients with acute chest pain or other symptoms raising suspicion of acute coronary syndrome.2003In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 253, no 3, p. 311-319Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: To evaluate the occurrence of elevation of serum biochemical markers for myocardial damage in the prehospital setting amongst patients who called for an ambulance due to a suspected acute coronary syndrome (ACS). DESIGN: Prospective observational study. SUBJECTS: All the patients who called for an ambulance due to suspected ACS. SETTING: South Hospital's catchment area in Stockholm and in the Municipality of Göteborg, Sweden between January and November in the year 2000, were included. INTERVENTIONS: On arrival of the ambulance crew, a blood sample was drawn for bedside analysis of serum myoglobin, creatine kinase MB and troponin I. A 12-lead electrocardiogram (ECG) was simultaneously recorded. MAIN OUTCOME MEASURES: Elevation of biochemical markers prior to hospital admission. RESULTS: In all, 511 patients participated on 538 occasions. Elevation of any biochemical marker was observed in 11% of all patients. The corresponding figure for patients developing myocardial infarction was 21%; for patients with myocardial ischaemia 8%; for patients with a possible myocardial ischaemia 4% and for patients with other diagnoses 5%. Amongst those who had a final diagnosis of acute myocardial infarction (AMI), 47% had ST-elevation on initial ECG and 57% had either ST-elevation or elevation of any biochemical marker. CONCLUSION: Bedside analysis of biochemical markers in serum is already feasible prior to hospital admission amongst patients with a suspected ACS. About 20% of patients with AMI have elevated biochemical markers at that stage. When found this data might increase the possibility of diagnosing an AMI very early in the course. However, false positives were found and whether this strategy will improve the triage of these patients in the prehospital setting remains to be proven.

  • 34. Svensson, L
    et al.
    Axelsson, C
    [external].
    Nordlander, R
    Herlitz, Johan
    [external].
    Prognostic value of biochemical markers, 12-lead ECG and patient characteristics amongst patients calling for an ambulance due to a suspected acute coronary syndrome.2004In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 255, no 4, p. 469-477Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: To evaluate whether a 12-lead ECG, together with a multi-marker strategy that used point-of-care measurements of myoglobin, creatine kinase (CK-MB) and troponin I, was able to predict patients at short- and long-term risk of death, when simultaneously considering age, gender, previous history, symptoms and clinical findings on arrival of the ambulance. DESIGN: Prospective observational study. SETTING AND SUBJECTS: Consecutive patients (n=511) in ambulances in Stockholm and Göteborg in Sweden who called for an ambulance due to chest pain or other symptoms raising a suspicion of acute coronary syndrome. INTERVENTION: In almost all patients, a diagnostic ECG, patient baseline characteristics and measurements of CK-MB, troponin I and myoglobin were recorded. RESULTS: In univariate analysis, the highest 30-day mortality (17%) was found amongst patients with the combination of ECG signs of myocardial ischaemia and the elevation of any biochemical marker. The highest 1-year mortality (20%) was found amongst patients with ECG signs of myocardial ischaemia and the elevation of any biochemical marker. Increasing age (RR 1.07; 95 CI 1.02-1.13) lack of symptoms of chest pain and a previous history of hypertension (3.02; 1.08-8.79) were independent predictors of 30-day mortality. Myoglobin was the only biochemical marker independently associated with 30-day mortality (6.66; 1.83-22.3). Increasing age (1.11; 1.06-1.16), previous history of diabetes (3.42; 1.41-8.25) heart failure (2.64; 1.26-5.52) and other symptoms than chest pain and dyspnoea (5.23; 2.14-12.76) were independent predictors of 1-year mortality. In many of the variables the confidence limits were wide. CONCLUSION: Amongst patients with a clinical suspicion of acute coronary syndrome, those with the combination of ECG signs of myocardial ischaemia and the elevation of any biochemical marker on arrival of the ambulance form a group with a particularly high risk of death. However, age as well as aspects of clinical history and type of symptoms independently contribute to prognostic information.

  • 35. Yusuf, S
    et al.
    Estrada-Yamamoto, M
    Reyes, CP
    Herlitz, Johan
    University of Borås, School of Health Science.
    Hjalmarson, Å
    Factors of Importance for QRS Complex Recovery after Acute Myocardial Infarction1982In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 211, no 3, p. 157-162Article in journal (Refereed)
    Abstract [en]

    The regression of the ECG signs of myocardial infarction has been studied in 101 patients. A significant increase in R wave amplitude and decrease in Q wave depth on the standard ECG was observed over three months. In 21% of the patients, Q waves disappeared completely. In inferior infarction, these changes were more apparent in the lateral V leads than in the inferior limb leads. Patients with intraventricular conduction defects were excluded. Two factors associated with the Q and R wave changes have been identified. Lower heart rates appeared to facilitate the recovery of R waves, and smaller infarcts, as assessed by peak LDH, showed greater ECG recovery. This study raises the interesting possibility that modification of the heart rate may affect favourably the healing process after an acute myocardial infarction.

  • 36. Ågård, A
    et al.
    Hermerén, G
    Herlitz, Johan
    [external].
    Should cardiopulmonary resuscitation be performed on patients with congestive heart failure? The role of the patient in the decision-making process2000In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 248, no 4, p. 279-286Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: There is an ongoing debate about patients' involvement in the decision of whether or not to start, cardiopulmonary resuscitation (CPR) in the case of cardiac arrest. The objective here is to analyse on what grounds patients with heart failure, who run a relatively high risk of suffering cardiac arrest, form their attitudes towards CPR and to what extent they want to be involved in making decisions concerning CPR. DESIGN: This study employs a combined qualitative and quantitative interview concerning patients' knowledge about CPR, their experiences and preferences regarding involvement in making decisions concerning CPR, and their willingness to undergo CPR. SETTING: The study was performed at the Department of Cardiology, Sahlgrens University Hospital, Gothenburg. SUBJECTS: The subjects involved were 40 patients with various stages of chronic heart failure. RESULTS: Many of the interviewees lacked fundamental knowledge of CPR. The majority of the patients opted for CPR no matter how small their chances of survival were. The issue had not earlier engaged their thoughts, even less been discussed with physicians. The patients relied on the physician's ability to judge if CPR was to be regarded as a potentially beneficial intervention or as an unmotivated one. Nevertheless, the patients welcomed the opportunity to take part in the decision-making process. CONCLUSION: In order to make ethically justified decisions, physicians should consider bringing up the question of CPR with patients suffering from heart failure at the point in time where the progressive disease gives rise to more severe symptoms, corresponding to NYHA classes IIIb-IV. In earlier stages of the disease, one can assume that the patient will opt for CPR unless he or she demonstrates a negative attitude towards life.

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